COMPLAINTS FILED ON: 11.02.2010
DISPOSED ON: 24.05.2011
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)
DATED THIS THE 24TH MAY 2011
PRESENT:- SRI. B.S. REDDY PRESIDENT
SMT. M. YASHODHAMMA MEMBER
SRI. A. MUNIYAPPA MEMBER
COMPLAINT Nos.284 to 291/2010
Complaint no.284/2010 Complainant | M/s Swastik General & Health Care Services (P) Ltd., Kamadhenu Corner, No.399, II Floor, 1st Main, 1st Stage, 3rd Phase, Manjunatha Nagar, WOC Main Road, Bangalore – 560 010. Rep: by its Authorized signatory Sri Jayaram K.B. |
Complaint no.285/2010 Complainant | M/s Swastik General & Health Care Services (P) Ltd., Kamadhenu Corner, No.399, II Floor, 1st Main, 1st Stage, 3rd Phase, Manjunatha Nagar, WOC Main Raod, Bangalore – 560 010. Rep: by its Authorized signatory Sri Jayaram K.B. |
Complaint no.286/2010 Complainant | M/s Swastik General & Health Care Services (P) Ltd., Kamadhenu Corner, No.399, II Floor, 1st Main, 1st Stage, 3rd Phase Manjunatha Nagar, WOC Main Raod, Bangalore – 560 010. Rep: by its Authorized signatory Sri Jayaram K.B. |
Complaint no.287/2010 Complainant | M/s Swastik General & Health Care Services (P) Ltd., Kamadhenu Corner, No.399, II Floor, 1st Main, 1st Stage, 3rd Phase, Manjunatha Nagar, WOC Main Raod, Bangalore – 560 010. Rep: by its Authorized signatory Sri Jayaram K.B. |
Complaint no.288/2010 Complainant | M/s Swastik General & Health Care Services (P) Ltd., Kamadhenu Corner, No.399, II Floor, 1st Main, 1st Stage, 3rd Phase, Manjunatha Nagar, WOC Main Raod, Bangalore – 560 010. Rep: by its Authorized signatory Sri Jayaram K.B. |
Complaint no.289/2010 Complainant | M/s Swastik General & Health Care Services (P) Ltd., Kamadhenu Corner, No.399, II Floor, 1st Main, 1st Stage, 3rd Phase, Manjunatha Nagar, WOC Main Raod, Bangalore – 560 010. |
Complaint no.290/2010 Complainant | M/s Swastik General & Health Care Services (P) Ltd., Kamadhenu Corner, No.399, II Floor, 1st Main, 1st Stage, 3rd Phase, Manjunatha Nagar, WOC Main Raod, Bangalore – 560 010. |
Complaint no.291/2010 Complainant | M/s Swastik General & Health Care Services (P) Ltd., Kamadhenu Corner, No.399, II Floor, 1st Main, 1st Stage, 3rd Phase, Manjunatha Nagar, WOC Main Raod, Bangalore – 560 010. Advocate: Sri. K. Surendra Babu V/s |
OPPOSITE PARTY | M/s New India Assurance Co. Ltd., D.O.-7, 5th Floor, D.J.C. Buildings, (Vokkaligara Bhavana), Hudson Circle, Bangalore – 560 027. Advocate: Sri. V. Subramani |
O R D E R
SRI. B.S. REDDY, PRESIDENT
These complaints are filed U/s. 12 of the Consumer Protection Act of 1986, by the same complainant against the same Opposite Party (herein after called as O.P) in respect of different claims seeking direction to the OP to reimburse the medical expenses and pay interest at 18% p.a. and for damages on the allegations of deficiency in service on the part of the OP.
Since the complainant and OP is common in all these complaints, the questions involved and the reliefs claimed are identical, in order to avoid the repetition of facts and multiplicity of reasonings all these complaints are stand disposed of by this common order.
2. The case of the complainant in complaint No.284/2010 is the complainant had taken group insurance policy valid for the period 01.01.2008 to 31.12.2008 from OP under the said group insurance policy. Shankar who is a worker in M/s Impex Granites Pvt. Ltd., is also one of the beneficiaries. The said Shankar sustained accidental injury to left foot due to fall of granite slab while working in M/s Impex Granites Pvt. Ltd., on 14.01.2008 at about 12-30 p.m. He was shifted to Nanjanagud Clinic, Nanjanagud for treatment and he was their as inpatient in the said hospital from 14.01.2008 to 13.01.2008. While admitting to the hospital the patient intimated that he had got Swastik Accident Care Policy and the said agency would be pay the bills. Accordingly the said hospital recorded the Corporate Agent is Swastik Accident Care in its bills. M/s Impex Granites Pvt. Ltd., intimated the complainant to pay the medical expenses as per the insurance policy on 31.01.2008. On 14.01.2008 the complainant intimated OP regarding the accident. Accordingly the complainant had paid the bills of the hospital amounting Rs.19,739/-. The complainant submitted all the medical bills and vouchers for the claim of insurance with OP on 29.04.2008. OP repudiated the claim by letter dated 28.07.2008 on the ground that there is breach of conditions and warranties (Late submission of claim papers and other discrepancies). After that the complainant again gave letter to OP to sympathetically consider the claim. Again by letter dated 02.06.2009 OP rejected the claim under the pretest “the competent authority regrets in party to reopen the claim”. OP just to reject the genuine claim there is delay in filing the claim papers, which is totally illogical and unjustified. The complainant is entitled for full reimbursement of the medical claim.
3. In the version filed contention of the OP has issued Tailor made Group Personal Accident Policy which is subject to memorandum of understanding entered into between the complainant and OP, further subject to the respective clauses attached covering the selective members of the complainant who are all covered under the said policy from time to time as declared. It is admitted that the complainant has sent a claim intimation letter dated 14.01.2008, but OP has received the said letter only on 29.04.2008. The complainant is called to produce the bank pass book / statement to establish the payment made to the hospital. The receipt issued by Nanjangud Clinic is in the name of Mr. Shankar is allegedly paid by cash. The complainant being a Private Limited Company and a Corporate Agent is supposed to pay medical bills to the respective hospital in the form of cheques only not by cash; hence the complainant is put to strict proof of the payment. It is submitted that as per the memorandum of understanding the complainant has to produce all supporting documents relating to the claim duly signed by the insured person within 30 days to the OP. The complainant has violated the terms and conditions of the MOU hence OP is not liable to indemnify the insured. The discharge summary is not in the prescribed form, but just on white paper with rubber stamp. The cash bill is in plain paper and even prescriptions and medicine purchase invoice of Rs.6,119/- are issued by the said hospital without substantiating whether they are authorized under the Shops and Establishment Act to sell the medicines. The said bill is created just for the purpose of this case and entire set of documents are prepared on the same day as one man show. Nanjangud Clinic does not fall under the definition for Hospital / Nursing Home as per Clause 3.2 and 3.2(a) of Clause Mediclaim (2007). The repudiation of the claim is while within the terms and conditions of the policy and MOU OP is not liable to reimburse any medical bill to the complainant as per the terms and conditions of the policy. Hence it is prayed to dismiss the complaint.
4. The case of the complainant in complaint No.285/2010 is the complainant had taken group insurance policy from the OP covering period from 01.01.2008 to 31.12.2008. Under the said group insurance policy Kodaiah is one of the beneficiaries. While he was traveling in Autoriksha toppled and sustained injuries to head and left side chest ribs. He was shifted to Matru Nursing Home & Trauma Care Centre, Bangalore. He took treatment as inpatient from 01.06.2008 to 05.06.2008. The complainant had paid the bills of the hospital pertaining to the said Kodaiah. T. amounting to Rs.17,277/- and submitted all the medical bills and vouchers for the claim of insurance with OP on 15.07.2008. OP by letter dated 17.09.2008 repudiated the claim stating that the required documents called for vide letter dated 07.08.2008 was not submitted even after lapse of more than a month. Kodaiah T. being an illiterate and a causal worker had not intimated the same to police, hence there is no FIR. The complainant is entitled for full reimbursement of the medical claim; the repudiation of the claim is not justified.
5. In the version filed OP contended that the policy issued is subject to memorandum of understanding entered into between the complainant and OP, further subject to the respective clauses attached hereto covering the selective members of the complainant. The complainant failed to state at what time the said Autorikshaw met with an accident and its registration mark and number. The accident intimation was submitted to this OP only after on 25.06.2008. The receipt No.1195 of Rs.17,277/- issued by Matru Nursing Home and Trauma Care Centre is in the name of Mr. T. Kodaiah is allegedly paid by cash. The complainant was supposed to pay all the medical bills to the respective hospitals in the form of cheques only not by cash; the complainant is put to strict proof of the same. OP asked certain documents their letter dated 07.08.2008 to comply with the requirements within 10 days. The said documents are not at all produced to this OP. The medical bills were submitted on 15.07.2008 along with other documents. As per MOU the complainant has to produce all the supporting documents within 30 days to this OP. The complainant has violated the terms and conditions of the MOU, hence OP is not liable to indemnify the insured. The pharmacy cash bills to the tune of Rs.5,552/- are issued by the said hospital without substantiating whether they are authorized under the Shops and Establishment Act, to sell the medicines. The said bills are created just for the purpose of this case. There is clear cut violation of terms and conditions of the policy / MOU / MV Act. OP repudiated the claim vide their letter dated 17.09.2008 OP by its letter dated 02.06.2009 regrets for their inability to reopen the claim in view of the reasons already stated vide their letter dated 17.09.2008. The complainant is not entitled for reimburse of medical claim there is no deficiency of service. Hence it is prayed to dismiss the complaint.
6. The case of the complainant in complaint No.286/2010 the complainant had taken group insurance policy from OP for the period from 12.10.2007 to 11.10.2008 under the said group insurance policy, Satish Kumar is one of the beneficiaries. On 23.08.2008 during the course of employment at TTP Technologies, Tumkur, the said Satish Kumar sustained injuries to both the hands and fingers in the fire accident and he was shifted to Vinayaka Hospital, Tumkur for first aid treatment. Later he was shifted to Matru Nursing Home and Trauma Care Centre for further treatment. He took treatment as inpatient in the said hospital from 24.08.2008 to 30.08.2008. As per the insurance policy the patient while admitting Matru Nursing Home and Trauma Care Centre asked to pay the bills of the Nursing Home. On 25.08.2008 complainant gave intimation to OP regarding hospitalization and also for verification. On the date of discharge, the complainant had paid the hospital and medical bills amounting to Rs.32,150/-. The complainant has submitted all the bills and vouchers for the claim of insurance with OP on 10.10.2008. By letter dated 30.12.2008 OP asked for certain clarification regarding accident. The complainant in turn had written a letter to M/s Ramph (India) for clarification. M/s Ramph (India) by its letter dated 17.02.2009 clarified about the injury sustained and OP requested to reconsider the claim. OP without caring for the explanation given repudiated the claim stating the files stands closed, on account of Sl. No.1 and 3 below – Sl. No.1 inspite of letters / remainders sent to you, you have not complained with the required papers / documents Sl. No.3 we are closing your claim file, on account of following reason – due to various discrepancies as per enclosed letter the amount claimed and the manner the claim has preferred has not satisfactory. After submitting the letter dated 18.02.2009 along with letter of M/s Ramph (India) the OP had neither answered the claim of the insured nor settle the claim. Hence the complaint.
7. In the version filed OP contended that the complainant has failed to state the time of the alleged accident and it is denied that Mr. Satish Kumar sustained injuries to both his hands and fingers in the fire accident and he was shifted to Matru Nursing Home and Trauma Care Centre for treatment and he had taken treatment in the hospital as inpatient. OP is not aware whether the complainant paid the bills of the hospital amounting to Rs.32,150/- It is not a true that the complainant has intimated the claim to the OP on 25.08.2008. It is denied that without applying the mind, without caring for the explanation given by M/s Ramph (India) OP repudiated the claim. The claim was repudiated on account of Sl. No.1 and 3. Sl. No.1 in spite of letter / reminders not complied with required papers / documents. Sl. No.3 their closing the claim file, on account of following reasons – due to various discrepancies as per enclosed letter, the amount claimed and the manner the claim was preferred was not satisfactory. OP after taking into consideration not only the letter dated 17.02.2009 of M/s Ramph (India), but also entire documents submitted by the complainant had admitted their inability to reopen the said claim by virtue of the previous claim repudiation letter dated 07.01.2009. The complainant called to produce their pass book / statement to establish the said payment to the hospital. The receipt No.1179 dated 30.08.2008 for Rs.32,150/- issued by Matru Nursing Home and Trauma Center is in the name of Mr. Satish Kumar is allegedly paid by cash. The complainant being a Private Limited Company and Corporate Agent working / procuring premium on behalf of this OP for a remuneration of agreed commission is supposed to pay all the medical bills to the respective hospitals are exclusively should be in the form of cheques only not by cash. The complainant has submitted medical bills to the tune of Rs.32,150/- on nil date, but during September – 2008 along with other documents. As per the MOU the complainant has produced all the supporting documents / vouchers / bills etc., relating to the claim duly signed by the insured person / beneficiary within 30 days to the OP. the complainant had violated the terms and conditions of the MOU, hence OP is not liable to indemnify the insured. The pharmacy cash bills in eight numbers to the tune of Rs.7,545/- are issued by the said hospital without substantiating whether they are authorized under the Shops and Establishment Act, to sell the medicines. The said bills are created just for the purpose of this case. OP repudiated the claim vide their letter dated 07.01.2009 and the same was duly served on the complainant on 20.01.2009 by virtue of breach and violation of terms and conditions of the policy and MOU i.e., “the required document called for vide our letter dated 13.11.2008 and 30.12.2008 are not submitted even after a lapse of more than a month”. OP by their RPAD letter dated 02.06.2009 regrets for their inability to reopen the claim in view of the reasons already stated vide their letter dated 07.01.2009. OP is not liable to reimburse any medical bill to the complainant as per the terms and conditions of the policy. Hence it is prayed to dismiss the complaint.
8. The case of the complainant in complaint No.287/2010 that the complainant had taken group insurance policy from OP for the period from 30.01.2008 to 29.01.2009. Under the said group insurance policy, the Nagaraju is also one of the beneficiaries. The said Nagaraju met with an accident on 14.03.2008, when his two wheeler skidded and fell down. Immediately he has shifted to Sri. Krishna Hospital, Kunigal for treatment. Nagaraju asked the complainant to pay the medical expenses as per the insurance policy. On the same day the complainant intimated to OP regarding the accident. Accordingly the complainant paid the bills of the hospitals amounting to Rs.14,100/-. The complainant submitted all the medical bills and vouchers for the claim of insurance with the OP on 29.04.2008. By a letter dated 22.07.2008 OP asked for certain clarifications. OP by letter dated 22.08.2008 has repudiated the claim illegally without any justification. OP repudiated the claim in standard format of the insured which reads as follows please note that your file stands closed, on account of Sl. No.1 and 3 – in spite of letter / reminders sent to you have not complied with the required papers / documents clarification, document not received so far, hence claim repudiated. On 10.09.2008 complainant submitted all the required documents and asked for reopening the case and settle the claim. OP had neither answered the claim nor settle the claim. Hence the complaint.
9. In the version filed by OP is contended that the policy which is subject to memorandum of understanding entered into between the insured / complainant and insurer / OP further subject to the respective clauses attached hereto. The complainant has not stated for whom the said Nagaraju was working. It is denied that the said Nagaraju met with an accident and was shifted to Sri Krishna Hospital, Kunigal. The complainant failed to state at what time, which place the two wheeler met with an accident and registration mark and number. The accident intimation was submitted to OP only after considerable delay. OP is not aware whether the complainant had paid medical bills of Nagaraju amounting to Rs.14,100/- by cash to the said hospital. The cash bill No.140 dated 17.03.2008 issued by the said hospital is not supported with receipt number, date, mode of payment and paid by whom etc., The complainant being a Private Limited Company and a Corporate Agent working / procuring premium on behalf of this OP for a remuneration of agreed commission is supposed to pay all the medical bills in the form of cheques only not by cash. OP by their letter dated 22.07.2008 has asked certain documents such as original FIR, Police Report being Road Traffic Accident, reason for not mentioning the name / age / sex / written on the X-ray report (No Bony Deformity or Fracture seen) the case sheet does not have the seal of the hospital etc., The complainant has to produce apart from the above said documents and clarifications, has to furnish the Panchanama, the reason for not reporting the accident to the police, description of the accident, employers letter for the accident, MLC register extract etc., but the complainant failed to produce the said documents, but just wrote one letter dated 29.07.2008 to the beneficiary to comply with the said requirements. The complainant submitted medical bills to the tune of Rs.14,100/- on 29.04.2008 along with other documents. As per the MOU the complainant has produced all the supporting documents relating to the claim duly singed by the insured person within 30 days to this OP. The complainant has violated the terms and conditions of the MOU hence this OP is not liable to indemnify the insured. The complainant / beneficiary has not produced any medicines purchased / pharmacy bills, if any. Under the said circumstances it is very much clear that inpatient bill and discharged summary is just created for the purpose of the case with ulterior motive to get an unlawful gain. The inpatient bill by the said hospital without substantiating whether they are authorized under the Shops and Establishment Act, to sell the medicines, just shown Rs.600/- towards Anesthesia given and drugs etc., The medico legal wound certificate is not served and acknowledged by the jurisdictional police. As far as the road traffic accident is concerned it is mandatory to lodge the complaint / FIR either by the owner of the offending vehicle or by the injured by virtue of Section 134(a)(b) and (c) of MV Act. Hence there exist clear cut violation of terms and conditions of the policy. On this ground OP is not liable to indemnify the insured. OP has repudiated the claim vide letter dated 22.08.2008 by virtue of breach and violation of the terms and conditions of the policy and MOU i.e., “the required clarification, documents not received so far – hence claim repudiated”. OP vide their letter dated 02.06.2009 regrets for their inability to reopen the claim as sought for by the complainant. In view of the reasons already stated vide their letter dated 22.08.2008. There is no deficiency of service on the part of the OP. OP is not liable to reimburse any medical bill to the complainant as per the terms and conditions of the policy. Hence it is prayed to dismiss the complaint.
10. The case of the complainant in complaint No.288/2010 is that the complainant had taken group insurance policy from OP for the period from 28.09.2007 to 27.09.2008. Under the said group insurance policy, the Nagendra Kumar A.S. is also one of the beneficiaries. For the complaint of Honey-bee biting, consequently facial edima with haematenusis and loose motion and low B.P. on 20.01.2008 the said Nagendra Kumar A.S. was admitted to Sarathi Puttaspathre, Doddaballapur for treatment and after treatment he was discharged on 23.01.2008. The said Nagendra Kumar A.S. asked the complainant to pay the medical expenses as per the insurance policy. On the very same day the complainant intimated to OP regarding the accident. Accordingly the complainant paid the bills of the hospitals amounting to Rs.6,573/-. The complainant submitted all the medical bills and vouchers for the claim of insurance with OP on 17.03.2008. On 09.06.2008 by a letter the OP has asked for 1) detailed summary 2) Hospital Receipt Rs.4,900/-. OP by a letter dated 22.08.2008 repudiated the claim for the following reason - inspite of letter / reminders sent to you have not complied with the required papers / documents - Documents required not submitted so far, hence claim repudiated.
At the time of submitting of bills and vouchers the complainant has submitted 1) Medical Certificate, which contains as details of discharge summary, 2) Cash Memo for Rs.4,900/- and 5 prescriptions along bills / receipts for having purchased medicines. The above mentioned hospital is situated in town of Doddaballapura and hence exact forms are not in the hospital, but all the ingredients of discharge summary had been mentioned in the medical certificate itself. Hence there is no reason to repudiate the claim. Hence the complainant is entitled for full reimbursement of the medical claim. Hence the complaint.
11. In the version filed by OP it is contended that the policy is issued subject to memorandum of understanding entered into between the parties and subject to the respective clauses hereto. The complainant has not stated from whom the said A.S. Nagendra Kumar was working. It is denied that the said Mr. A.S. Nagendra Kumar was admitted the hospital and he has taken medical treatment from 20.01.2008 to 23.01.2008 in Sarathi Puttaspathre, Doddaballapura. The complainant sent claim intimation to the OP after lapse of considerable time, but not immediately as alleged on 20.01.2008. OP does not aware whether the complainant has paid the hospital bills amounting to Rs.6,573/- which includes cash memo issued by Sarathi Puttaspathre for Rs.4,900/-. The complainant has failed to produce the hospital receipts to show the mode of payment, date of payment etc., and the detailed discharged summary in the prescribed format as sought by OP vide their letter dated 09.06.2008. The cash memo No.1214 dated 23.01.2008 for Rs.4,900/- issued by the said hospital is in the name of Mr. A.S. Nagendra Kumar is allegedly paid by cash. The complainant being a Private Limited Company and a Corporate Agent working / procuring premium on behalf of the OP for a remuneration of agreed commission is supposed to pay all the medical bills in the form of cheques only not by cash. The complainant has submitted medical bills to the tune of Rs.4,900/- on 17.03.2008, but not for Rs.6,573/- as claimed vide their letter dated nil, but January – 2008 i.e., 4 numbers of prescriptions – 4852, 4853, 4854 and 4855 dated 20.01.2008, 21.01.2008, 22.01.2008 and 23.01.2008 respectively i.e., for Rs.1,673/- along with other documents. As per the MOU the complainant has produced all the supporting documents relating to the claim duly signed by the insured person within 30 days to the OP. The complainant has violated the terms and conditions of the MOU hence this OP is not liable to indemnify the insured. The complainant has not submitted discharge summary to the OP which clearly established the case is nothing but a false and frivolous with sole intention to grab unlawful gain. Sarathi Puttaspathre not suffixed with “Nursing Home” which clearly establishes that the said clinic is not falls under the definition for Hospital / Nursing Home as per clause 3.2 and 3.2(a) of Clause Mediclaim (2007). Hence there exist clear cut violation of terms and conditions of the policy. OP repudiated the claim vide its letter dated 22.08.2008 by virtue of breach and violation of terms and conditions of the policy and MOU i.e., “documents required not submitted so far – hence claim repudiated”. There is no deficiency of service what so ever on the part of the OP. OP is not liable to reimburse the medical bills to the complainant as per the terms and conditions of the policy. Hence it is prayed to dismiss the complaint.
12. The case of the complainant in complaint No.289/2010 is that the complainant had taken group insurance policy from OP for the period from 01.08.2007 to 31.07.2008. One Kariappa is one of the beneficiaries in the said group insurance. The said Kariappa met with an accident on 27.05.2008 at about 23-30 hours. He was a pillion rider of motor cycle bearing registration No.KA-41 J-1893; the said motor cycle was driving by one Reetesh Kumar Gupta. Immediately after accident the injured was shifted to Sharavathi Hospital and then shifted to Nimhans for treatment. After examination in Nimhans the doctors referred to a general hospital for further management and observation. After that the injured Kariappa was admitted to Abhaya Hospital on 28.05.2008 and discharged on 17.07.2008. The said Kariappa asked the complainant to pay the medical expenses as per the insurance policy. On 28.05.2008 the complainant intimated the OP regarding the accident. Accordingly the complainant had paid the bills of the hospitals. All the medical bills and vouchers for the claim for the claim of insurance with OP has been submitted on 29.08.2008. But the OP returned the file on the ground that bills and receipts were not produced along with the claim letter. The complainant again submitted all the medical bills and vouchers with receipts for the claim of insurance with OP on 30.04.2009. OP by letter dated 11.05.2009 has repudiated the claim with any justification. The claim has been repudiated on the grounds that accident was on 27.05.2008, but the papers were submitted on 30.04.2009, after the lapse of 11 months. The reason for the in ordinate delay in submitting the papers is not explained. No proof is submitted for the treatment taken at Nimhans Hospital, the bill and discharge summary is from Abhaya Hospital. As per the discharge summary the date of payment and date of discharge is from 28.05.2008 to 17.07.2008 for Rs.2,02,500/-. The receipt No.09241 is dated 17.04.2009 after the lapse of 8 months raised in the name of Swastik and not in the name of patient. The other bill amount to Rs.1,02,500/- issued in the name of Kariappa to enable OP to proceed further.
Immediately after the accident Kariappa and Reetesh Kumar were shifted to nearest Sharavathi Hospital. After first aid treatment Kariappa was shifted to Nimhans as there was head injury. After investigation and observation, the doctors of Nimhans advised him to admit to any General Hospital for further management and observation. After that the said Kariappa admitted to Abhaya Hospital, Wilson Garden, Bangalore for further treatment. Discharge summary of Abhaya Hospital has clearly mentioned all these facts. Complainant had issued Swastik Helath Care Policy to Kariappa to upper limit of Rs.1,00,000/-. On the request of Kariappa, the complainant requested Abhaya Hospital to discharge the patient without taking money from him and complainant had undertaken to pay Rs.1,00,000/- towards the bill amount at the future date. Accordingly the complainant had paid money to Abhaya Hospital on 17.04.2009 through cheque bearing No.063838. For the said amount a receipt also been given by Abhaya Hospital, after payment of bill on 17.04.2009 to Abhaya Hospital the said receipt has been produced for reimbursement on 30.04.2009. Hence there is no inordinate delay. The upper limit of insurance policy is Rs.1,00,000/-, if the complainant produces original bills to the extent of Rs.2,02,500/- will OP reimburse the amount to an extent of Rs.2,02,500/-? Because of this reason the complainant had produced bill for Rs.1,00,000/-, OP does not have right to ask for original bills for Rs.2,02,500/- has been given to OP. The receipt dated 17.04.2009 for Rs.1,00,000/- was also produced in the said receipt it is mentioned that the amount paid by Swastik General Health Care Services (P) (L) towards No.12157 through cheque No.063838 dated 17.04.2009, the said bill No.12157 belongs to Kariappa. But OP did not consider and settle the claim. Because of the non settlement of the claim complainant has been put into great and irreparable injury. Thus the complainant claimed Rs.1,00,000/- towards reimbursement of the medical expenses with interest at 18% p.a. and for damages for mental agony. Hence the complaint.
13. In the version filed by OP contended that the policy has issued Tailormade Group Personal Accident Policy which is subject to memorandum of understanding entered into between the insured / complainant and insurer / OP and further subject to respective clauses attached hereto covering the selective members of the complainant who are all covered under the said policy. It is admitted that the complainant has covered one of their members being beneficiary under the said policy by name Mr. Kariappa. It is denied that the said Kariappa met with an accident as a pillion rider on motorcycle and he was admitted to Sharavathi Hospital and then to Nimhance, then he has taken to Abhaya Hospital. It is denied that the said Kariappa asked the complainant to pay medical expenses as per the insurance policy and as such complainant intimated OP with regard to the accident on 28.05.2008 accordingly the complainant has paid the hospital bills. It is admitted that the complainant has submitted medical bills and vouchers with OP on 29.08.2008; OP returned file on ground that the complete bills and receipts were not produced along with the claim documents. The complainant subsequently produced the said documents on 30.04.2009. As per the MOU the complainant has produce all the supporting documents / vouchers / bills relating to the claim duly signed by the insured within 30 days. The complainant has violated the terms and conditions of the MOU, hence OP is not liable to indemnify the insured. The claim was repudiated on the following grounds:
a) Accident was on 27.05.2008 but the papers were submitted on 30.04.2009 i.e., after lapse of eleven months. The reason for the inordinate delay in submitting the papers is not explained.
b) No proof is submitted for the treatment taken at Nimhans Hospital, the delay and discharge summary is from Abhaya Hospital.
c) As per the discharge summary the date of admission and date of discharge is from 28.05.2008 to 17.07.2008 with a bill for Rs.2,02,500/-. The receipt No.09241 is dated 17.04.2009 after a lapse of eight months raised in the name of Swastik General and Health Care and not in the name of patient.
d) The other bill amount to Rs.1,02,500/- are in duplicate bills raised in the name of Kariappa.
e) To submit original bills for Rs.2,02,500/- issued in the name of Kariappa.
Even though the insured Kariappa was discharged from the hospital on 17.07.2008 a sum of Rs.1,00,000/- only was paid by cheque No.063838 dated 17.04.2007 was paid by the complainant and no receipt for the balance amount was produced to the OP. However duplicate receipts for Rs.7,500/-, Rs.20,000/-, Rs.25,000/-, Rs.36,000/-, Rs.14,000/- all dated 20.02.2009 paid by various cheques issued in the name of beneficiary are produced, the reason for non production of original receipts are not explained. The complainant and the beneficiary are called to produce their bank pass books / statements to establish the said payment to the hospital by way of cheque, to establish that the said cheques are honoured. It is denied that the said Kariappa was admitted to Nimhans then to Abhaya Hospital. OP is does not aware that on the request of Kariappa, the complainant requested the Abhaya Hospital to discharge the patient without taking money, since he is insured for an upper limit of Rs.1,00,000/- for the said policy and the complainant had undertaken to pay Rs.1,00,000/- towards the bill amount at the future date. It may be true that the complainant had paid money to Abhaya Hospital on 17.04.2009 through cheque bearing No.063838 for which a receipt was also issued by the said hospital and the same was produced to the OP, but certainly there is a delay in payment by nine months. The beneficiary Kariappa allegedly sustained injury in the road traffic accident and rightly an FIR / complaint in Cr. No.0090 dated 28.05.2008 was lodged before the jurisdictional traffic police station against the rider of the offending motorcycle bearing No.KA-41 J-1983 by the complainant one Mr. Bharath Kumar Gupta. Considering the facts and circumstances of the case the documents available before the OP that certainly the beneficiary would have already filed an MVC case before any of the Hon’ble Tribunal and either said case would have been pending for disposal or award shall have already have been passed and hefty compensation would have been received by the beneficiary kariappa and the entire medical bill to the tune of Rs.2,02,500/- apart from compensation under different heads. The complainant / beneficiary are called to produce an affidavit before this Forum deposing that no claim application in MVC case was filed and have no intention to file in future also claiming the entire Rs.2,02,500/- which includes the sum insured of Rs.1,00,000/- covered under the said policy. The complainant / beneficiary are called to produced MLC register extract, charge sheet, wound certificate, entire police and hospital records before this Forum. OP by its letter dated 21.04.2009 and 11.05.2009 has asked certain original documents from the complainant and the same was not complied with in total. OP has repudiated the claim by virtue of breach and violation of terms and conditions of the policy and MOU, the complainant is not entitled for compensation for mental agony. There exists no deficiency of service on the part of the OP. Hence it is prayed to dismiss the complaint with costs.
14. The case of the complainant in complaint No.290/2010 is that the complainant had taken group insurance policy from OP valid from 30.01.2008 to 29.01.2009. Under the said policy Sujit D Rai working as a gas welder in M/s Precision Car Care Centre is one of the beneficiaries. The said Sujit D Rai sustained burn injury on his face and on both the hands on 01.05.2008 while welding at M/s Precision Car Care Centre. Immediately he was shifted to A.J. Hospital & Research Centre, Kuntikana, Mangalore for treatment and took treatment as inpatient from 01.05.2008 to 12.05.2008. While admitting to the hospital the patient intimated that he had got Swastik Accident Care Policy and the said agency would be pay the bills. M/s Precision Car Care Centre had intimated the complainant to pay the medical expenses as per the policy. On 06.05.2008 the complainant intimated the OP regarding the accident and the complainant paid the bills of the hospital amounting to Rs.30,185/-. Sujit D Rai had spent Rs.30,185/- on his treatment. He himself had paid some medicine bills amounting to Rs.5,513/- and balance amount of Rs.24,672/- is due to hospital intimated the complainant to pay the medical expenses as per the insurance policy. Accordingly the complainant paid the bills of the hospitals amounting to Rs.24,946/-. The complainant submitted all the medical bills and vouchers for the claim of insurance with OP on 27.06.2008 for Rs.30,185/-. OP repudiated the claim by its letter dated 13.11.2008 without any justification. The claim has been repudiated on the ground that inspite of letters / remainders sent, complainant has not complied with the required papers / documents. OP is closing the claim file on account of required documents not submitted, even after 2 months. In letter dated 28.07.2008 OP asked for production of numbered receipt for hospital inpatient bill for Rs.24,672/-. The receipt dated 12.12.2008 for Rs.24,672/- was also produced. In the said receipt it is mentioned that amount paid by Swastik General Health Care Services Pvt. Ltd., towards bill No.126326 through cheque No.857560 dated 31.12.2008. OP did not consider and settle the claim. Hence the complaint.
15. In the version filed by OP it is contended that the policy issued is subject to memorandum of understanding entered into between the insured / insurer and subject to the respective clauses attached thereto covering the selective members of the complainant who are all covered under the said policy. It is denied that Mr. Sujit D Rai sustained burn injuries on 01.05.2008 while welding at M/s Precision Car Care Centre and he was shifted to A.J. Hospital & Research Centre for treatment. It is denied that M/s Precision Car Care Centre intimated the complainant to pay the medical expenses as per the insurance policy and on 06.05.2008 the complainant intimated the OP regarding the accident and accordingly the complainant paid bills to the hospital amounting to Rs.30,185/-. As per the receipt No.038 dated 12.12.2008 the amount paid was Rs.24,672/- only and not Rs.30,185/-. It is admitted that the complainant has intimated the claim to OP on 06.05.2008. It is denied that Sujit D. Rai had paid Rs.30,185/- and balance amount Rs.24,672/- was due to hospital and accordingly the complainant has paid the said amount to the hospital. The inpatient bill of the hospital has shown the drugs and pharmacy was supplied to the tune of Rs.7,791/- as such under the said circumstances the question of buying the medicines to the tune of Rs.5,513/- by the beneficiary without the support of prescriptions does not arise. No such prescriptions and medical bills for the alleged purchase of medicines at Rs.5,513/- was produced before the OP. OP by its letter dated 28.07.2008 had informed the complainant to produce the numbered receipt for hospital inpatient bill for Rs.24,672/-, but complainant has produced the said receipt No.038 dated 12.12.2008 vide their letter dated 19.12.2008 i.e., after the repudiation of claim on 13.11.2008. It is submitted that why the said hospitalization bill was not settled / paid as on the date of discharge of patient on 12.05.2008. The claim was repudiated on the ground that inspite of letters / memorandums sent the complainant has not complied with the required papers / documents. Further the required documents not submitted even after two months (OP letter dated 28.07.2008 calling for numbered receipts from the hospital). There is intentional delay on the part of the complainant to produce the said receipt to the OP and claiming the reimbursement without making the payment to hospital for more than seven months as such there exist a clear cut violation of terms and conditions of the policy and the provisions of MOU. OP by taking into consideration of all the documents available had rightly repudiated the claim and had admitted their inability to reopen the said claim. The complainant is called to produce the bank pass book / statement to establish the said payment to the hospital. The receipt No.038 dated 12.12.2008 for Rs.24,672/- is in the name of the complainant, is allegedly paid by cheque bearing No.857560 dated 12.12.2008 (a post dated cheque 31.12.2008). As per the MOU the complainant has produced all the supporting documents relating to the claim within 30 days to the OP. The complainant has breached / violated the terms and conditions of the MOU hence OP is not liable to indemnify the insured. The pharmacy cash bills in ten numbers to the tune of Rs.7,791/- are issued by the said hospital are already reflected in inpatient bill. The receipt / post dated cheque is just created for the purpose of this case until and unless it is substantiated with the bank statement / pass book for its honour. OP is not liable to reimburse any medical bill to the complainant as per the terms and conditions of the policy. Hence it is prayed to dismiss the complaint with costs.
16. The case of the complainant in complaint No.291/2010 is that the complainant had taken group insurance policy from OP for the period from 30.10.2007 to 29.10.2008 and one Nagesh a cooli worker is one of the beneficiaries in the said group insurance. The said Nagesh while loading the electric pole, an iron channel attached to the said pole accidentally fallen on his leg on 19.01.2008 and sustained injury. He was shifted A.J. Hospital & Research Centre, Kuntikana, Mangalore for treatment and took treatment as inpatient from 19.01.2008 to 05.02.2008. The patient intimated the hospital that he had got Swastik Accident Care Policy and the said agency would pay the bills. Accordingly the hospital recorded the corporate agent is Swastik Accident Care. Nagesh had spent Rs.28,159/- on his treatment. He himself had paid some medicine bills amounting to Rs.3,213/- and balance amount of Rs.24,946/- was paid by the complainant to the hospital. The complainant submitted all medical bills and vouchers for the claim of insurance with OP on 17.03.2008 for Rs.28,159/-. By letter dated 09.06.2008 OP asked the complainant to produce “receipt towards payment of hospital bills”. Accordingly the complainant had paid the bills of the hospital and produced the receipts. OP by its letter dated 22.08.2008 repudiated the claim on the ground that inspite of letters, the complainant not complied with the required papers / documents and that by consent by the claim has been withdrawn. The receipt dated 12.12.2008 for Rs.24,946/- was also produced in the said receipt, it is mentioned that amount paid by Swastik General Health Care Services (P)(L) towards bill No.109168 through cheque No.857561 dated 12.12.2008. But OP did not consider and settle the claim, hence the complaint.
17. In the version filed by OP it is contended that the policy issued is subject to memorandum of understanding entered into between the insured and insurer. Further subject to the respective clauses attached thereto covering the selective members of the complainant who are all covered under the said policy. It is denied that Mr. N. Nagesh while loading the electric pole to lorry sustained injury on 19.01.2008 and he had taken treatment as inpatient in the A.J. Hospital & Research Centre from 19.01.2008 to 05.02.2008. It is denied that Nagesh had spent Rs.28,159/- on his treatment and he has paid Rs.3,213/- towards medicine bills and balance amount of Rs.24,946/- was paid by the complainant to the hospital. As per the receipt No.039 dated 12.12.2008 the amount paid was Rs.24,946/- only and not Rs.28,159/-. Even though the cheque No.857561 for Rs.24,946/- was post dated one i.e., 29.12.2008 which is allegedly paid after ten months from the date of alleged discharged even that cheque if further subject to honour by the bankers of the complainant. It is admitted that the complainant had intimated the claim to the OP on 06.05.2008. The inpatient bill of the hospital has shown the drugs and pharmacy was supplied to the tune of Rs.4,693/- as such the question of buying the medicines to the tune of Rs.3,213/- by the beneficiary without the support of prescriptions does not arise. No such prescriptions and medical bills for the alleged purchase of medicines at Rs.3,213/- produced before the OP. OP by its letter dated 09.06.2008 informed the complainant to produce the numbered receipt for hospital inpatient bill for Rs.24,946/-, but the complainant has produced the receipt dated 12.12.2008 i.e., after the repudiation of claim on 22.08.2008. It is submitted that why the said hospitalization bill was not settled as on the date of discharge of patient on 05.02.2008. The claim was repudiated on the grounds that inspite of letters / reminders not complied with the required papers / documents by virtue of the terms and conditions of the policy and MOU. There is intentional delay on the part of the complainant to produce the said receipt to the OP and claiming the reimbursement without making the payment to hospital for more than ten months as such there exist a clear cut violation of terms and conditions of the policy and the provisions of MOU. OP after taking into consideration not only the receipt dated 12.12.2008, but all the documents available, had rightly repudiated the claim and had admitted their inability orally to reopen the said claim by virtue of their previous repudiated letter by 22.08.2008. The complainant is called to produce bank pass book / statement establish to the hospital. As per MOU the complainant produces all the supporting documents within 30 days to the OP in support of the claim. The complainant had violated the terms and conditions of the MOU, hence OP is not liable to indemnify the insured. The pharmacy cash bills in six numbers to the tune of Rs.3,213/- are allegedly issued by the said hospital are already might have reflected in the inpatient bill as pharmacy / drug charges which are all dated in between 14.01.2008 to 23.01.2008 i.e., during inpatient period. One of the said 5 prescriptions bearing No.536686 dated 14.01.2008 for Rs.935/- which clearly establishes that the said bill (still the said bill is not produced either to the OP or before this Forum). It is not ruled out, it is already spend of Rs.935/- which falls under one of the exclusion of the said policy, after thought idea both the complainant and beneficiary in collusion with the hospital created the subsequent to hospital documents to accommodate for the unlawful gain. There exist no deficiency of service whatsoever on the part of the OP. OP is not liable to reimburse any medical bill to the complainant as per the terms and conditions of the policy. Hence it is prayed to dismiss the complaint with costs.
18. The complainant had taken Group Insurance Policy from OP under the said Group Insurance Policy the complainant claims reimbursement of Medical expenses of he injured who were beneficiaries under the policy on the ground that the medical expenses incurred by all the injured / beneficiaries under the policy are paid by the complainant as a corporate agent and now the complainant is claiming reimbursement of the said medical expenses paid.
19. The main common defense of the OP in all these complaints is that OP has issued tailor made Group Personal Accident Policy, which is subject to Memorandum of understanding entered into between the insured / the complainant and insurer / OP herein respectively, further subject to the respective clauses attached here to covering the selective members of the complainant but are all covered under the said policy from time to time as declared.
20. Further, the common defense is that the complainant being a private limited company and a corporate agent is supposed to pay medical bills to the respective hospitals in the form of cheques only not by cash. As per the Memorandum of understanding the complainant has to produce all supporting documents relating to the claim duly signed by the insured within 30 days after completion of the treatment. The complainant has violated the terms and conditions of the MOU. Hence OP is not liable to indemnify the injured.
21. In complaint No.284/2010 the defense is that the Nanjanagudu Clinic where the insurer is stated to have taken medical treatment does not fall under the definition for hospital / Nursing Home as per Clause-3.2 and 32(a) and claim (2007).
22. The worker by name Shankar in M/s Impex Granite Private Limited, sustained accidental injury to his left foot due to fall of granite slab on 14.01.2008 at about 12.30 p.m. He was shifted to Nanjangud Clinic, Nanjangud and he was there as inpatient from 14.01.2008 to 30.01.2008. The complainant claims that the medical bills of the said hospital amounting to Rs.19,739/- was paid by the complainant and submitted all the medical bills and vouchers for the claim of insurance with OP on 29.04.2008. OP called upon the complainant produced the Bank Pass Book / statement to establish the payment made to the hospital. The receipt issued by the Nanjangud Clinic is in the name of Mr.Shankar is allegedly paid by cash. Further the discharge summery is not in the prescribed form just on white paper with rubber stamp and the cash bill is in a plane paper and even prescribes and medicine purchase invoice of Rs.6,119/- ae issued by the said hospital without substantiating whether they are authorized under the shops and establishment act of sell the miscellaneous. Thus, it is contended that the said bill is created just for purposes of this case and enter setup documents are prepared on the same day as one man show. The repudiation of the claim is within terms and conditions of the policy and MOU, OP is not liable to reimburse any medical bill to the complainant as per the terms and conditions of the policy.
23. Arguments on both sides heard. The learned Advocate for the OPs filed common written arguments with regard to MOU for all the complaints and written arguments on merits in each of the complaints.
24. Points for consideration are:
Point No.1:- Whether the complainants have proved
the deficiency in service on the part of
the OPs in all these complaints?
Point No.2:- If so, whether the complainants are
entitledfor the reliefs now claimed?
Point No.3:- To what Order?
25. We record out findings on the above points are:
Point No.1:-
Point No.2:-
Point No.3:- As per final Order.
R E A S O N S
26. The main contention of the OPs is that the complainant has executed a MOU on 16.07.2007, a copy of which has been marked as EX.R.1. By virtue of the said MOU a specially devised policy to suit the requirements of the complainants was issued namely “Tailor made Group Personal Accident Policy” subject to payment of premium as per the Tariffs Rates of premiums stated therein both for the “Personal Accident premium and Medi-claim premium” for the respective sum insured chosen by the complainant. The complainant has not paid any premium as agreed upon towards the Medi-claim Premium and just paid only Personal Accident Premium as per the tariff incorporated therein but claim in the entire medical bills / expenses under Personal Accident coverage policy which is not within the scope of the policy / MOU. The specially devised policy after due negotiations as shown very much concession as far as the Personal premiums are concerned and charged only rate of premium at Rs.1 per thousand, whereas the correct premium chargeable is at Rs.1,50/- to Rs.2/- for sum of insured of Rs.1,000/-. The terms and conditions of both the policy are different but clubbed together by virtue of clauses attached thereto i.e., Medi-claim clause and personal accident clause as far as the medical expenses compensation are concerned. In all these cases in reference the medical expenses are claimed either to the actual or up to the sum insured as the case may be only under the personal accident policy.
Under the Personal Accident Policy coverage available is as per Clause attached such as detailed below:-
i. Death at 100% of Sum insured.
ii. Loss of both eyes or two entire hands or two entire feet or one entire hand & one entire foot or sight of one eye & loss of one entire hand or entire foot 100% of Sum insured.
iii. Sight of one eye or physical separation of one entire hand or one entire foot at 50% of the sum insured.
iv. Total & irrecoverable loss of hand or a foot without physical separation 50% of sum insured.
v. Permanent Total Disability of the insured person from engaging in any employment / occupation at 100% sum insured.
vi. If such injury result in the total & partial irrecoverable loss or of use or actual loss by physical separation of the individual percentages of eh sum insured as stated in the said Clause.
In these cases no such injuries have caused but the complainant as if he is paid the premium for both the Personal Accident & Medi-claim Insurance, claiming the entire medical expenses by paying only Personal Accident Premium. The premiums chargeable for Medi-claim Policy are more than 7 to 12 times of the Personal Accident Premium based on the age of the insured persons.
27. Since the Medical Reimbursement is allowable only if any compensation is allowed under the above stated heads otherwise no medical reimbursement will be payable. Even such a medical extension expenses shall be reimbursable up to 40% of the valid claim or 10% of the capital sum insured whichever is less.
28. The details of the claims made by the complainants in all these complaints is as shown in the chart below:-
Serial Nos. | Complaint Nos. | Name of the beneficiary / insured | Amount claimed |
1. | CC.284/2010 | Shankar | Rs.19,739/- |
2. | CC.285/2010 | Kodaiah | Rs.17,277/- |
3. | CC.286/2010 | Sathish Kumar | Rs.32,150/- |
4. | CC.287/2010 | Nagaraj | Rs.14,100/- |
5. | CC.288/2010 | Nagendra Kumar A.S., | Rs.6,573/- |
6. | CC289/2010 | Kariyappa | Rs.1,00,000/- |
7. | CC.290/2010 | Sujith D. Rai | Rs.30,185/- |
8. | CC.291/2010 | Nagesh | Rs.28,159/- |
The main controversy between the parties as to whether the group insurance taken by the complainant was a Medi-claim policy or Personal Accidental Policy. OP has produced Personal Accident Insurance (individual) proposal form-salient features of Personal Accident Policy. As per the said proposal form and salient features of Personal Accident Policy, the policy provides for payment of certain amount as compensation, depending upon the capital sum insured (CSI) for death or disablement due to accident caused by external, violation and visible means. The scope of the policy is Worldwide and the compensation payable (indicated as % of CSI) are as under:-
1) Death | 100% | Table of Benefits |
2) Loss of 2 limbs, 2 eyes or 1 limb & 1 eye | 100% | D-As per (1) C-As per (1) to (4) B-As per (1) to (5) A-As per (1) to (6) |
3) Loss of 1 limb or one eye | 50% |
4) PTD from injuries other than those named above | 100% | |
5) Permanent Partial Disablement | % as determined 100% |
6) TTD @ 1% of CSI upto 100 Weeks: However, limited to CSI | Max of Rs.3,000/- per week |
The policy can be extended to cover Medical expenses –for additional premium – upto 40 % of vlid claim or 10% of CSI, whichever is less. Insured will enjoy cumulative bonus @ 5% of every claims-free year subject to max 50%, if policy is renewed in time. Family Discount of 10% is allowed on total premium if the insured covers family members also under the policy. The policy offers two additional benefits (without extra premium)-(i) expenses for carriage of dead body to theplace of residence (when death occurs away from home) – Rs.2,500/- or 2% or CSI whichever less and (ii) Education grant to dependent children in case of death/PTD of insured person-Max, Rs.5,000/- for 1 child or Rs.10,000/- for 2 children premium rates depend upon the Risk Group to which the proposer belongs and also the Table of Benefits opted.
29. OP produced in each case the documents with Memo and got marked as EX.R1 to R8. EX.R1 is the policy of the copy issued. The policy period is from 01.01.2008 to 31.12.2008 net premium had shown is Rs.6,960/- the total members 116 in sum insured of Rs.50,000/- each for accidental death only and Rs.50,000/- for ME/accident the total sum insured is shown at Rs.58,000/- risk covered is shown as per G.P.A. police clause subject partial is shown as the policy covers Rs.60 per head for covering persons between the age 3 years to 65 years in payment of compensation for accidental death up to Rs.50,000/- and hospitalization / ME including for treatment of solely accidental injury up to Rs.50,000/-under subject conditions head it is shown that 116 members are covered for Rs.50 each total cover due to accident and Rs.50,000/- medical expenses incurred due to accidental injuries only. Premium is collected as under.
Rs.60 X 116 members + 6,960 + service tax at 12.36 of Rs.860/- total premium Rs.7,820/-. As per the policy, it becomes clear that the policy covers only medical expenses incurred due to accidental injuries only. The premium paid for each of the members is Rs.60. The accidental injuries as mentioned in personal accident injuries policy (individual) provides that if at any time during the currency of this Policy, the insured person shall sustain any bodily injury resulting solely and directly from accident caused by external violent and visible means, then the company shall pay to the insured or his legal personal representative(s) as the case may be, the sum or sums hereinafter set forth, that is to say
a) If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of the death of the insured, the capital sum insured stated in the schedule hereto.
b) If such injury shall within Twelve calendar months of its occurrence be the sole and direct cause of the total and irrecoverable loss of
i) Sight of both eyes or of the actual loss by physical separation of two entire hands or two entire feet, or of one entire hand and one entire foot or of such loss of sight of one eye and such loss of one entire hand or one entire foot, the Capital Sum insured stated in the schedule hereto.
ii) Use of two hands or two feet, or of one hand or one foot, or of such loss of sight of one eye and such loss of use of one hand or one foot, the Capital Sum Insured stated in the Schedule hereto.
c) If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of the total and irrecoverable loss of
i) The sight of one eye or the actual loss by physical separation of one entire hand or of one entire foot, fifty percent(50%) of the Capital Sum insured stated in the schedule hereto.
ii) Total and irrecoverable loss of hand or a foot without physical separation, fifty percent (50%) of the Capital Sum Insured stated in the Schedule hereto.
NOTE: For the purpose of Clause(b) and (c) above, physical separation of a hand means separation at or above the wrist and of the foot means at or above the ankle.
d) If such injury shall, as a direct consequence thereof, immediately permanently totally and absolutely disable the insured Person from engaging in any employment or occupation of any description whatsoever, then a lump sum equal to hundred percent(100% of the Capital Sum Insured.
e) If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of the total and/or partial and irrecoverable loss of use or of the actual loss by physical separation of the following, then the percentage of the Capital Sum Insured as indicated below shall be payable.
Percentage of Capital
Sum Insured
i)Loss of toes-all……………………………………………………….20
Great-both phalanges ……………………………………………..05
Great-one phalanx
Other than great, if more than one toe lost each……………..01
ii) loss of hearing-both ears………………………………………..75
iii) Loss of hearing-one ear…………………………………………30
iv) Loss of four fingers and thumb of one hand…………………40
v) Loss of four fingers…………………………………………………35
vi) Loss of thumb-both phalanges………………………………….25
i) Loss of toes-all…………………………………………………..20
Great-both phalanges………………………………………….05
Great-one phalanx……………………………………………..02
Other than great, if more than one toe lost each………..01
ii) Loss of hearing-both ears……………………………………..75
iii) Loss of hearing-one ear………………………………………..30
iv) Loss of four fingers and thumb of one hand……………..40
v) Loss of four fingers……………………………………………..35
vi) Loss of thumb-both phalanges………………………………25
-one phalanx…………………………………………………….10
vii) Loss of index finger
-three phalanges or
-two phalanges or
-one phalanx…………………………………………………….10
viii) Loss of middle finger
-three phalanges or
-two phalanges or
-one phalanx…………………………………………………….06
ix) Loss of ring finger
-three phalanges or
-two phalanges or
-one phalanx…………………………………………………….05
x) Loss of little finger
-three phalanges or
-two phalanges or
-one phalanx…………………………………………………….04
xi) Loss of metacarpals
-first or second(additional)of
-third, fourth or
-fifth (additional)……………………………………………….03
xii) Any other permanent partial (Percentage as assessed by)
disablement (PPD) the Panel Doctor of the Company)
f) If such injury shall be sole and direct cause of Temporary Total Diablement, (TTD) then so long as the Insured Person shall be totally disabled from engaging in any employment or occupation of any description whatsoever, a sum at the rate of one percent (1%) of the Capital Sum Insured stated in the Schedule hereto per week, but in any Provided that the compensation payable under the foregoing Sub Clause (f) shall not be payable for more than 100 weeks in respect of any one injury calculated from the date of commencement of disablement and in no case shall exceed the Capital Sum Insured.
30. In the complaint No.284/2010 Tailor-made Group Personal Accident Policy bearing No.671500/42/07/05/00000580 valid from 01.01.2008 to 31.12.2008 for the sum insured of Rs.50,000/- and collected a premium of Rs.60/- @ Rs.1 per Rs.1000/- sum insured + 20% medical expenses i.e., Rs.12/- in all a sum of Rs.72/- which is subject to Memorandum of understanding entered into between the insured/the complainant and insurer/OP herein respectively further subject to the respective Clauses attached hereto covering the selective members of the complainant who are all covered under the said policy from time to time as declared.
31. In the complaint No.285/2010 Tailor-made Group Personal Accident Policy bearing No.671500/42/07/05/00000579 valid from 01.01.2008 to 31.12.2008 for the sum insured of Rs.1,00,000/- and collected a premium of Rs.100/- @ Rs.1 per Rs.1000/- sum insured + 20% medical expenses i.e., Rs.20/- in all a sum of Rs.120/- which is subject to Memorandum of understanding entered into between the insured/the complainant and insurer/OP herein respectively further subject to the respective Clauses attached hereto covering the selective members of the complainant who are all covered under the said policy from time to time as declared.
32. In the complaint No.286/2010 Tailor-made Group Personal Accident Policy bearing No.671500/42/07/05/00000441 valid from 12.10.2007 to 11.10.2008 for the sum insured of Rs.1,00,000/- and collected a premium of Rs.100/- @ Rs.1 per Rs.1000/- sum insured + 20% medical expenses i.e., Rs.20/- in all a sum of Rs.120/- which is subject to Memorandum of understanding entered into between the insured/the complainant and insurer/OP herein respectively further subject to the respective Clauses attached hereto covering the selective members of the complainant who are all covered under the said policy from time to time as declared.
33. In the complaint No.287/2010 Tailor-made Group Personal Accident Policy bearing No.671500/42/07/05/00000649 valid from 30.01.2008 to 29.01.2009 for the sum insured of Rs.1,00,000/- and collected a premium of Rs.100/- @ Rs.1 per Rs.1000/- sum insured + 20% medical expenses i.e., Rs.20/- in all a sum of Rs.120/- which is subject to Memorandum of understanding entered into between the insured/the complainant and insurer/OP herein respectively further subject to the respective Clauses attached hereto covering the selective members of the complainant who are all covered under the said policy from time to time as declared.
34. In the complaint No.288/2010 Tailor-made Group Personal Accident Policy bearing No.671500/42/07/05/00000392 valid from 28.09.2007 to 27.09.2008 for the sum insured of Rs.1,00,000/- and collected a premium of Rs.100/- @ Rs.1 per Rs.1000/- sum insured + 20% medical expenses i.e., Rs.20/- in all a sum of Rs.120/- which is subject to Memorandum of understanding entered into between the insured/the complainant and insurer/OP herein respectively further subject to the respective Clauses attached hereto covering the selective members of the complainant who are all covered under the said policy from time to time as declared.
35. In the complaint No.289/2010 Tailor-made Group Personal Accident Policy bearing No.671500/42/07/05/00000228 valid from 01.08.2007 to 31.07.2008 for the sum insured of Rs.1,00,000/- and collected a premium of Rs.100/- @ Rs.1 per Rs.1000/- sum insured + 20% medical expenses i.e., Rs.20/- in all a sum of Rs.120/- which is subject to Memorandum of understanding entered into between the insured/the complainant and insurer/OP herein respectively further subject to the respective Clauses attached hereto covering the selective members of the complainant who are all covered under the said policy from time to time as declared.
36. In the complaint No.290/2010 Tailor-made Group Personal Accident Policy bearing No.671500/42/07/05/00000649 valid from 30.01.2008 to 29.01.2009 for the sum insured of Rs.1,00,000/- and collected a premium of Rs.100/- @ Rs.1 per Rs.1000/- sum insured + 20% medical expenses i.e., Rs.20/- in all a sum of Rs.120/- which is subject to Memorandum of understanding entered into between the insured/the complainant and insurer/OP herein respectively further subject to the respective Clauses attached hereto covering the selective members of the complainant who are all covered under the said policy from time to time as declared.
12.
Accordingly we proceed to pass the following:
O R D E R
The complaints are allowed in part.
1. In complaint No. OP is directed to settle the claim of the complainant at Rs./- and pay litigation cost of Rs./- to the complainant.
2. In complaint No. OP is directed to settle the claim of the complaint at Rs./- and pay litigation cost of Rs./- to the complainant.
3. In complaint No. OP is directed to settle the claim of the complainant at Rs./- and pay litigation cost of Rs./- to the complainant.
This order is to be complied within four weeks from the date of this order.
Send the copy of this order to both the parties free of cost.
This original order shall be kept in the file of the complaint No.284/2010 and a copy of it shall be placed in other respective files.
(Dictated to the Stenographer and typed in the computer and transcribed by him, verified and corrected, and then pronounced in the Open Court by us on this the 23rd day of February – 2011.)
PRESIDENT
MEMBER MEMBER
Snm:
